A systematic review investigating the identification, causes, and outcomes of delays in the management of chronic limb-threatening ischemia and diabetic foot ulceration

Nickinson, Andrew; Bridgwood, Bernadeta; Houghton, John S M; Nduwayo, Sarah; Pepper, Coral; Payne, Tanya; Bown, Matthew J.; Davies, Robert; Sayers, Rob

doi:10.1016/j.jvs.2019.08.229

Cited by 60 publications

(67 citation statements)

References 66 publications

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“…7 A recent systematic review attributes delays in initiating appropriate treatment to limitations in patient self-care, inaccurate healthcare assessment, and barriers to referral. 4 Of these, perhaps the most challenging to overcome are those related to the patient, who is often impeded in performing recommended…”

Section: Introductionmentioning

confidence: 99%

Recurrence rates suggest delayed identification of plantar ulceration for patients in diabetic foot remission

Petersen

Bus

Rothenberg

et al. 2020

BMJ Open Diab Res Care

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IntroductionFoot ulcers are a common and costly complication of diabetes, and delays in treatment can result in impaired healing, infection, hospitalization, and lower extremity amputation.Research design and methodsWe aimed to determine whether patterns in plantar diabetic foot ulcer (DFU) recurrence coincided with typical intervals between routine preventive care appointments, which would suggest that delays exist between ulcer development and identification. We completed an analysis of existing data from two multicenter studies in 300 total participants. We analyzed unadjusted counts of DFU binned in weekly intervals and defined ‘exam periods’ as intervals from 2 to 4 weeks, from 6 to 8 weeks, within 1 week of 3 months and within 1 week of 6 months. We tested whether recurrence rates during exam periods were equivalent to rates outside exam periods. We estimated the delay between DFU development and DFU identification such that the rate of development would have been constant.ResultsDuring exam periods, a total of 43 DFUs were identified (43/86=50%) despite the fact that these periods represent only 23.5% of follow-up in aggregate. Accounting for censoring, the annualized incidence during exam periods was 0.68 DFU/year (CI 0.48 to 0.89) in contrast to 0.25 DFU/year (CI 0.18 to 0.32) outside exam periods (incidence ratio=2.8, CI 1.8 to 4.3). We estimated delays between DFU occurrence and identification to average 15.3 days (IQR 7.4–23.7 days).ConclusionsThese findings have potential implications for practice, particularly related to the value of telehealth and in-home monitoring of patients in diabetic foot remission. Additionally, there are implications for study design, which should consider the impact of interval censoring and attempt to control for confounders related to frequency and timing of exams.

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Section: Introductionmentioning

confidence: 99%

Recurrence rates suggest delayed identification of plantar ulceration for patients in diabetic foot remission

Petersen

Bus

Rothenberg

et al. 2020

BMJ Open Diab Res Care

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“…Despite this, evidence suggests time delays are common throughout the treatment pathway. 3 While the causes of delays will differ even between individual departments, removing unnecessary barriers between healthcare specialities is appreciated as a key factor in providing timely care. 4,6 The concept of vascular limb salvage services has grown in prominence over the last decade as a solution to this problem, providing seamless access to specialist vascular assessment, revascularisation and surgical debridement (often referred to as the 'toe-and-flow' model).…”

Section: Discussionmentioning

confidence: 99%

“…1,2 Even in the age of MDT working however, lengthy time delays in the management of both CLTI and diabetic foot ulceration (DFU) remain, with these delays having detrimental effects on patient outcomes. 3 Reasons cited for these delays include difficulties accessing specialist vascular services by 'community' and 'non-specialist' healthcare professionals, along with unnecessary assessment by 'non-specialist' professionals prior to referral. [4][5][6] In an attempt to help improve care and reduce rates of major amputation, the Vascular Society of Great Britain and Ireland (VSGBI) recently published its 'Peripheral Arterial Disease Quality Improvement Framework' (PAD QIF), which for the first time stipulates target times for the assessment and treatment of patients with CLTI ( Figure 1).…”

Section: Introductionmentioning

confidence: 99%

Can a rapid-access vascular limb salvage service improve one-year amputation outcomes for patients with chronic limb-threatening ischaemia?

Nickinson

Dimitrova

Rate

et al. 2019

Preprint

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“…Many problems, however, still exist within the referral and management pathways for patients, often resulting in lengthy time delays in accessing vascular services. 4 Two recent surveys of healthcare professionals both identified difficulties with accessing specialist vascular consultation and non-invasive imaging as major barriers to care. 5,6 This defies the contemporary trend towards greater multidisciplinary and collaborative working.…”

Section: Introductionmentioning

confidence: 99%

The utilisation of vascular limb salvage services in the assessment and management of chronic limb‐threatening ischaemia and diabetic foot ulceration: A systematic review

Nickinson

Houghton

Bridgwood

et al. 2020

Diabetes Metabolism Res

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Specialist vascular limb salvage services have gained prominence as a new model of care to help overcome barriers which exist in the management of patients with chronic limb-threatening ischaemia (CLTI) and/or diabetic foot ulceration (DFU). This systematic review aims to explore the nature of reported services, investigate their outcome in the management of CLTI/DFU, and assess the scope and quality of the evidence base to help make recommendations for future practice and research. A systematic search of MEDLINE, Embase, The Cochrane Library, Scopus and CINAHL, from 1st January 1995 to 18th January 2019, was performed. Specialist vascular limb salvage services were defined as those services conforming to the definition of "centres of excellence" within the 2019 Global Vascular Guidelines. A study protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42019123325). In total, 2260 articles were screened, with 12 articles (describing 11 services) included in a narrative synthesis. All services ran akin to the "toe-and-flow" model, with a number of services having additional core input from diabetology, microbiology, allied health professionals and/or internal/vascular medicine. Methodological weaknesses were identified within the design of the included articles and only one was deemed of high quality. The inception of services was associated with improved rates of major amputation; however, no significant changes in minor amputation or mortality rates were identified. Further research should adopt more a standardised study design and outcomes measures in order to improve the quality of evidence within the literature.

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A systematic review investigating the identification, causes, and outcomes of delays in the management of chronic limb-threatening ischemia and diabetic foot ulceration

Cited by 60 publications

References 66 publications

Recurrence rates suggest delayed identification of plantar ulceration for patients in diabetic foot remission

Recurrence rates suggest delayed identification of plantar ulceration for patients in diabetic foot remission

Can a rapid-access vascular limb salvage service improve one-year amputation outcomes for patients with chronic limb-threatening ischaemia?

The utilisation of vascular limb salvage services in the assessment and management of chronic limb‐threatening ischaemia and diabetic foot ulceration: A systematic review

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